内镜黏膜下剥离术治疗直肠病变

目的探讨内镜黏膜下剥离术治疗直肠病变的应用价值。方法对肠镜发现的较大直肠腺瘤和黏膜下肿瘤应用头端弯曲的针形切开刀进行内镜黏膜下剥离术（ESD）治疗：（1）黏膜下注射生理盐水抬高病变，使病变与肌层相分离；（2）预切开病变周围黏膜；（3）剥离病变下方黏膜下层结缔组织，完整切除病变。结果12例低位直肠病变，大小0．6～4．5cm（平均2．8cm），均成功完成ESD治疗。术后11例病理确诊基底和切缘未见病变累及；1例腺癌累及黏膜下层病例接受外科根治手术，手术标本病理未见肿瘤残留。ESD手术时间（自黏膜下注射至完整剥离病变）30～120min（平均52min）。术中出血量平均约75ml，均经电凝、氩离子凝固术和止血夹成功止血，未出现需再次肠镜下治疗的出血。2例剥离深至肌层，出现皮下气肿和少量膈下游离气体，保守治疗好转。9例1个月后肠镜复查，创面基本愈合。结论ESD是治疗消化道病变的新方法，不仅能切除较大的病变，还能提供完整的病理学诊断资料。以往需要外科手术的消化道早期癌和部分黏膜下肿瘤，通过ESD可以达到同样的治疗效果。     

Rectal compliance in females with obstructed defecation

PURPOSE: This study was designed to investigate whether rectal compliance is altered in females with obstructed defecation. METHODS: Eighty female patients with obstructed defecation and 60 control subjects were studied. Rectal compliance was measured with an infinitely compliant polyethylene bag. This bag was inserted in the rectum and inflated with air to selected pressure plateaus (range, 0–60 mmHg; cumulative steps of 2 mmHg with a duration of ten seconds) using a computer-controlled electromechanical barostat system. Volume changes at the levels of distending pressures were recorded. The distending pressures, needed to evoke first sensation of content in the rectum, earliest urge to defecate, and the maximum tolerable volume were noted. RESULTS: In all cases, the compliance curve had a characteristic triphasic (S-shaped) form. The mean compliance curve obtained from the patients was identical to that of the controls. However, the course of the compliance curve fell above the normal range (mean + 2 SD) in 14 patients. In ten (71 percent) of these patients, a large rectocele was seen at evacuation proctography. Such a rectocele was observed in only five patients (7.6 percent) with a normal compliance curve (P<0.001). Eighty percent of the controls experienced earliest urge to defecate during the second phase of the curve. In 75 percent of the patients, this occurred in the third phase. The mean pressure threshold for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients compared with control subjects. Ten of the patients experienced no sensation at all in the pressure range between 0 and 60 mmHg. CONCLUSION: In females with obstructed defection, the compliance of the rectal wall is normal.     

Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

Clinicopathological characteristics and prognosis of rectal well-differentiated neuroendocrine tumors

Background  To clarify the oncological outcome of rectal well-differentiated neuroendocrine tumors (W/D NETs), we examined the clinicopathological characteristics and prognosis of patients with this neoplasm. Materials and methods  A total of 23 patients who underwent surgical treatment with lymph node dissection for rectal W/D NETs between 1973 and 2007 were reviewed. Results  Median tumor size measured preoperatively was 13 mm (range, 4–25 mm), and the median number of dissected lymph nodes was 16 (range, 1–46). The incidence of lymph node metastasis was 61% (14 of 23 cases). The smallest W/D NETs with lymph node metastasis was 10 mm in diameter. All the patients without lymph node metastasis survived without recurrence. Among 11 patients who had only regional lymph node metastasis, only one developed liver metastasis and died 13 months after initial surgery. Among three patients with lateral pelvic lymph node metastasis, two survived more than 5 years, although two had liver metastasis. Conclusions  Because the incidence of lymph node metastasis is very high in patients with rectal W/D NETs greater than 10 mm in diameter, radical surgery is required. In this series, the outcome of rectal W/D NETs patients with lateral pelvic lymph node metastasis was better than expected.     

Long-Term Results of Balloon Catheter Dilation of Lower Gastrointestinal Tract Stenoses

PURPOSE: This study involved a prospective evaluation of the results of the balloon catheter dilation of lower gastrointestinal stenoses.METHODS: First a guide-wire was introduced into the stenosis followed under x-ray control by a double-lumen balloon catheter, or directly through the endoscope a balloon catheter, with progressive dilation under pressures of 1.5 to 3 atm. The result was assessed via the decreased indentation of the balloon and the increased diameter of the stenosis.RESULTS: Between January 1985 and November 2002, 133 dilations were performed on 57 patients. The cause of the stenosis was postoperative stenosis in 44 patients, Crohns disease in 6, ulcerative colitis in 2, postirradiative stenosis in 1, ischemic stenosis in 1, and scarring of the anus in 3 patients. Four of the stenoses were localized to the anus, 45 to the rectum, 7 to the colon, and 1 to the terminal ileum. The average diameter of the stenosis was increased from 7.2 (range, 1–14) mm to 19.7 (range, 14–25) mm. Colostomies were closed in 11 of 17 cases. In five patients, the ileus state ceased, and the three colocutaneous fistulas healed rapidly. In 17 of 57 patients, reoperation was proposed. In one patient, fever as a complication was treated with antibiotics.CONCLUSIONS: The dilation of benign stenoses of the lower gastrointestinal tract with a balloon catheter is an effective and safe method, which in most cases (70 percent) results in long-term elimination of the obstructive symptoms, so that surgery can be avoided.Presented in part at the United European Gastroenterology Week, Birmingham, United Kingdom, October 18 to 23, 1997.     

便秘型肠易激综合征肛门直肠动力学的临床研究

目的　观察便秘型肠易激综合征 (IBS)的肛门直肠动力学改变。方法　采用灌注式测压装置测定 18例便秘型IBS患者和 15例健康人的肛门直肠压力、直肠对容量刺激的最低敏感量、最大耐受量及直肠顺应性。结果　便秘型IBS的直肠、肛门内外括约肌静息压力、内括约肌主动收缩压、模拟排便时直肠收缩压、内外括约肌净减压与对照组相比无显著性差异。肛门 直肠屏障压便秘型IBS组高于对照组 (P <0 0 5 )。直肠对容量刺激的最低敏感量便秘型IBS组低于对照组 (P <0 0 5 ) ,最大耐受量及顺应性均高于对照组 (P <0 0 1)。结论　便秘型IBS存在肛门直肠动力学异常 ,这种异常可能是导致便秘的原因     

Diffuse cavernous hemangioma of the rectosigmoid colon

Diffuse cavernous hemangioma of the rectosigmoid colon is an uncommon benign vascular lesion. We report 5 cases of diffuse cavernous hemangioma, focusing on the clinical features, diagnosis procedure and treatment. Five patients have undergone sphincter–saving procedures, 3 cases had coloanal sleeve anastomoses and 1 patient each had pull–through anastomosis and lower anterior resection. During the follow–up, which ranged from 3 to 10 years, 3 patients had no further anal bleeding and 2 patients had minor intermittent anal bleeding. Continence for normal stool was satisfactory in all patients. In conclusion, sphincter–saving procedure is most appropriate and curative approach for the treatment of diffuse cavernous hemangioma. Imaging study plays an important role in the diagnosis, preoperative staging and follow–up.     

Sigmoid schwannoma： A rare case

Schwannomas are rare tumors derived from the cells of Schwann that form the neural sheath. When located in the gastrointestinal tract, they constitute together with leiomyoma, leiomyoblastoma, and leiomyosarcoma, the gastrointestinal stromal tumors (GIST). Peripheral nerve sheath tumors represent 2-6% GIST with most common location, the stomach and the small intestine. Schwannomas of the colon and rectum are extremely rare and radical excision with wide margins is mandatory, due to their tendency to recur locally and become malignant, if left untreated. In the present study, we report a rare case of a sigmoid schwannoma, which was successfully treated in our department and reviewed the literature.     

Massive Hematochezia from Acute Hemorrhagic Rectal Ulcer in Patients with Severe Comorbid Illness: Rapid Control of Bleeding by Per Anal Suturing of Bleeder Using Anoretractor

Purpose Massive hematochezia from acute hemorrhagic rectal ulcer can arise in patients with severe comorbid illness who are bedridden for long periods. If the bleeder is not found and treated immediately, the bleeding will cause deterioration of health and even threaten life. The results of the current study show how quickly and safely per anal suturing can treat acute hemorrhagic rectal ulcer. Methods From January 2003 to December 2003, the records of 26 patients who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. The identification of acute hemorrhagic rectal ulcer was confirmed by clinical and anoscopic examination. Results Most of these patients were elderly and bedridden (14 men; median age 69 years). Main comorbid illnesses existed in all patients and included liver cirrhosis (8 patients, 31 percent), sepsis (13 patients, 50 percent), cerebral vascular accident (15 patients, 58 percent), respiratory failure (13 patients, 50 percent), and malignancy (7 patients, 27 percent). Effective hemostasis was achieved in all patients by direct suture of bleeding ulcer. No complications developed relative to the per anal suturing procedure among any patients. Although 11 patients developed recurrent hematochezia, 9 patients responded to repeated therapy. The risk factors associated with recurrent bleeding were severity of disease and abnormal coagulation. Conclusions When massive hematochezia occurs in bedridden patients with severe comorbid illness, it is essential to investigate the lower rectum, which often is affected by acute hemorrhagic rectal ulcer. Recognition of this clinical presentation will result in early identification and therapy. Per anal suturing of a bleeder at the bedside provides a quick, safe, and successful management of acute hemorrhagic rectal ulcer.     

60例成年人直肠电刺激脑诱发电位特点及结果分析

目的探讨正常人直肠电刺激脑诱发电位（CEP）的正常值及波形特征。 方法检查者将刺激电极经肛置入受试者直肠内,在头顶部Cz点放置记录电极,参考电极置于前额部Fz点,使用英国Oxford公司肌电诱发电位仪采样分析。 结果所有检测对象均记录有直肠电刺激脑诱发电位,各波参数范围分别是：P1波潜伏期（45.55±3.26）ms,N1波（101.71±15.71）ms,P2波（198.35±27.70）ms,P1/N1波幅（5.62±1.58）μV,N1/P2波幅（8.26±2.48）μV。直肠电刺激脑诱发电位各波潜伏期及波幅在性别、年龄分组间比较,差异无统计学意义。经一般线性回归分析发现,在控制年龄分组、性别后,波幅随BMI增加而降低,BMI每增加1 kg/m²,P1/N1波幅平均下降0.234 μV（P=0.011）,N1/P2波幅平均下降0.320 μV（P=0.027）。 结论直肠电刺激脑诱发电位提供了一种简单、有效的评估直肠到大脑皮层感觉神经通路的方法。本研究对了解功能性胃肠疾病中的脑肠互动作用具有重要价值。本研究的检测结果及其影响因素分析,可供后续临床研究借鉴。